Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association

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1 Electrical Bone Growth Stimulation Page 1 of 42 Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Title: Electrical Bone Growth Stimulation of the Appendicular Skeleton Professional Institutional Original Effective Date: July 11, 2002 Original Effective Date: July 11, 2002 Revision Date(s): March 26, 2013; May 7, 2013; March 7, 2014 Revision Date(s): March 26, 2013; June 7, 2013; March 7, 2014 Current Effective Date: March 7, 2014 Current Effective Date: March 7, 2014 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. DESCRIPTION In the appendicular skeleton, electrical stimulation (with either implantable electrodes or noninvasive surface stimulators) has been investigated for the treatment of delayed union,, and fresh fractures. Electrical and electromagnetic fields can be generated and applied to bones through the following methods: Surgical implantation of a cathode at the fracture site with the production of direct current (DC) electrical stimulation. Invasive devices require surgical implantation of a current generator in an intramuscular or subcutaneous space, while an electrode is implanted within the fragments of bone graft at the fusion site. The implantable device typically remains functional for 6 to 9 months after implantation, and, although the current generator is removed in a second surgical procedure when stimulation is completed, the

2 Electrical Bone Growth Stimulation Page 2 of 42 electrode may or may not be removed. Implantable electrodes provide constant stimulation at the or fracture site but carry increased risks associated with implantable leads. Noninvasive electrical bone growth stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads/electrodes are placed on either side of the fusion site and worn for 24 hours per day until healing occurs or up to 9 months. In contrast, pulsed electromagnetic fields are delivered via treatment coils that are placed over the skin and are worn for 6 8 hours per day for 3 to 6 months. Combined magnetic fields deliver a time-varying magnetic field by superimposing the time-varying magnetic field onto an additional static magnetic field. This device involves a 30-minute treatment per day for 9 months. Patient compliance may be an issue with externally worn devices. Semi-invasive (semi-implantable) stimulators use percutaneous electrodes and an external power supply obviating the need for a surgical procedure to remove the generator when treatment is finished. In the appendicular skeleton, electrical stimulation has been used primarily to treat tibial fractures, and thus this technique has often been thought of as a treatment of the long bones. According to orthopedic anatomy, the skeleton consists of long bones, short bones, flat bones, and irregular bones. Long bones act as levels to facilitate motion, while short bones function to dissipate concussive forces. Short bones include those composing the carpus and tarsus. Flat bones, such as the scapula or pelvis, provide a broad surface area for attachment of muscles. Despite their anatomic classification, all bones are composed of a combination of cortical and trabecular (also called cancellous) bone. Each bone, depending on its physiologic function, has a different proportion of cancellous to trabecular bone. At a cellular level, however, both bone types are composed of lamellar bone and cannot be distinguished microscopically. Nonunion The definition of a fracture has remained controversial. The original U.S. Food and Drug Administration (FDA) labeling defined as follows: "A is considered to be established when a minimum of 9 months has elapsed since injury and the fracture site shows no visibly progressive signs of healing for minimum of 3 months." Others have contended that 9 months represents an arbitrary cut-off point that does not reflect the complicated variables that are present in fractures, i.e., degree of soft tissue damage, alignment of the bone fragments, vascularity, and quality of the underlying bone stock. Other proposed definitions of involve 3 to 6 months time from original healing, or simply when serial x-rays fail to show any further healing. Delayed Union Delayed union refers to a decelerating bone healing process, as identified in serial x-rays. (In contrast, serial x-rays show no evidence of healing.) When lumped together, delayed union and are sometimes referred to as "ununited fractures."

3 Electrical Bone Growth Stimulation Page 3 of 42 Regulatory Status The noninvasive OrthoPak Bone Growth Stimulator (BioElectron) received U.S. Food and Drug Administration (FDA) premarket approval in 1984 for treatment of fracture. Pulsed electromagnetic field systems with FDA premarket approval (all noninvasive devices) include Physio-Stim from Orthofix Inc., first approved in 1986, and OrthoLogic 1000, approved in 1997, both indicated for treatment of established secondary to trauma, excluding vertebrae and all flat bones, in which the width of the defect is less than one-half the width of the bone to be treated; and the EBI Bone Healing System from Electrobiology, Inc., which was first approved in 1979 and indicated for s, failed fusions, and congenital pseudarthroses. No distinction was made between long and short bones. The FDA has approved labeling changes for electrical bone growth stimulators that remove any timeframe for the diagnosis. No semi-invasive electrical bone growth stimulator devices with FDA approval or clearance were identified. POLICY A. Noninvasive electrical bone growth stimulation may be considered medically necessary as treatment of fracture s or congenital pseudoarthroses in the appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper extremities, pelvis, and lower extremities). The diagnosis of fracture must meet ALL of the following criteria: at least 3 months have passed since the date of fracture; serial radiographs have confirmed that no progressive signs of healing have occurred; and the patient can be adequately immobilized and is of an age likely to comply with non-weight bearing. B. Noninvasive electrical bone growth stimulation is considered medically necessary as a treatment of joint fusion. C. Experimental / Investigational applications of electrical bone growth stimulation include, but are not limited to, immediate post-surgical treatment after appendicular skeletal surgery, stress fractures, or for the treatment of fresh fractures or delayed union. D. Implantable and semi-invasive electrical bone growth stimulators are considered experimental / investigational.

4 Electrical Bone Growth Stimulation Page 4 of 42 Policy Guidelines 1. Fresh Fracture A fracture is most commonly defined as fresh for 7 days after the fracture occurs. Most fresh closed fractures heal without complications with the use of standard fracture care, i.e., closed reduction and cast immobilization. 2. Delayed Union Delayed union is defined as a decelerating healing process as determined by serial x-rays, together with a lack of clinical and radiologic evidence of union, bony continuity, or bone reaction at the fracture site for no less than 3 months from the index injury or the most recent intervention. 3. Nonunion There is not a consensus for the definition of s. One proposed definition is failure of progression of fracture-healing for at least 3 consecutive months (and at least 6 months following the fracture) accompanied by clinical symptoms of delayed/ (pain, difficulty weight bearing). (1) 4. The original FDA labeling of fracture s defined s as fractures that had not shown progressive healing after at least 9 months from the original injury. This timeframe is not based on physiologic principles but was included as part of the research design for FDA approval as a means of ensuring homogeneous populations of patients, many of whom were serving as their own controls. Some fractures may show no signs of healing, based on serial radiographs as early as 3 months, while a fracture may not be diagnosed in others until well after 9 months. The current policy of requiring a 3-month timeframe for lack of progression of healing is consistent with the definition of as described in the clinical literature. RATIONALE Noninvasive Bone Growth Stimulation Nonunion The policy regarding electrical bone stimulation as a treatment of of fractures of the appendicular skeleton is based on the labeled indications by the U.S. Food and Drug Administration (FDA). The FDA approval was based on a number of case series in which patients with s, primarily of the tibia, served as their own control. These studies suggest that electrical stimulation results in subsequent unions in a significant percentage of patients. (2-6) A 2008 systematic review of electromagnetic bone growth stimulation by Griffin and colleagues included 49 studies, 3 of which were randomized controlled trials (RCTs). (7) The 2 RCTs that included patients with and the single RCT that included patients with delayed union are described below.

5 Electrical Bone Growth Stimulation Page 5 of 42 A 1994 RCT by Scott and King compared capacitive coupled electric fields with sham treatment (dummy unit) in 23 patients with (fracture at least 9 months old and without clinical or radiographic sign of progression to union within the last 3 months) of a long bone. (8) Patients with systemic bone disorders, synovial pseudoarthrosis, or fracture gap of greater than half the width of the bone were excluded. In this trial, electrodes were passed onto the skin surface through holes in the plaster cast. Twenty-one patients completed the protocol (10 treatment and 11 controls). Six months after beginning treatment, an orthopedic surgeon and a radiologist, neither of them involved in the patients management, examined radiographs and determined that 6 of 10 in the treatment group healed, while none of those in the control group healed (p=0.004). In 2003, Simonis et al. compared pulsed electromagnetic field stimulation and placebo treatment for tibial shaft fractures ununited at least 1 year after fracture, no metal implant bridging the fracture gap, and no radiologic progression of healing in the 3 months before treatment. (9) All 34 patients received operative treatment with osteotomy and unilateral external fixator prior to randomization. Treatment was delivered by external coils. Patients were assessed monthly for 6 months, and clinical and radiographic assessments were conducted at 6 months. Treatment was considered a failure if union was not achieved at 6 months. In the treatment group, 89% of fractures healed compared with 50% in the control group (p=0.02). While a larger percentage of smokers in the treatment group healed than compared with those in the control group, the number of smokers in each group was not comparable, and the difference in healing rates between groups was not statistically significant. The authors conclude that the available evidence supports the use of pulsed electromagnetic field therapy (PEMF) in the treatment of of the tibia and suggest that future trials should consider which modality of electromagnetic stimulation and in which anatomical sites the treatment is most effective. Delayed Union Shi et al. reported a randomized sham-controlled trial that included 58 patients with delayed union of surgically-reduced long-bone fractures (femur, tibia, humerus, radius or ulna). (10) Delayed union was defined as a failure to heal after at least 16 weeks and not more than 9 months following surgical reduction and fixation of the fracture. Patients with fracture, defined as failure to heal after more than 9 months, were excluded from the study. Treatment with 8 hours of PEMF per day was stopped when no radiographic progression was observed over 3 months or when union was achieved, with union defined as no pain during joint stressing or during motion at the fracture site and callus bridging for 3 out of 4 cortices on blinded assessment. Three months of treatment resulted in a slight, but not statistically significant, improvement in the rate of union between PEMF-treated patients and controls (38.7% vs. 22.2%). The success rate was significantly greater with PEMF (77.4% vs. 48.1%) after an average of 4.8 months of treatment. The time to union was not significantly different between PEMF (4.8 months, range, 2 to 12) and sham controls (4.4 months, range 2 to 7). In a double-blind RCT by Sharrard from 1990, PEMF stimulation was compared with a sham procedure using a dummy device in 45 patients with delayed union of the tibia. (11) Stimulators were positioned on the surface of the plaster cast. Treatment began 16 to 32 weeks after injury. Patients with fracture gaps greater than 0.5 cm after reduction, systemic disease, or taking steroids were excluded, as well as patients with marked bony atrophy or hypertrophy. Fifty-one patients were recruited, and 45 completed the protocol (20 treatment and 25 control). In the treatment group, 3 patients achieved union, 2 achieved probable union, 5 showed progression to

6 Electrical Bone Growth Stimulation Page 6 of 42 union, and 10 showed no progress after 12 weeks. In the control group, none had united, 1 had probably united, 3 progressed toward union, and 17 showed no progress. The policy regarding electrical stimulation of delayed unions is based on a 1992 TEC Assessment of the RCT by Sharrard, (12) which offered the following conclusions: Sharrard reported radiographic evidence of healing at the end of the 12-week treatment period. Radiographs were rated separately by a radiologist and an orthopedic surgeon. Their inconsistent rating methods and uncertain comparability in their findings make the radiographic evidence difficult to interpret. In addition, it is uncertain whether radiographic evidence of healing after 12 weeks of treatment, an intermediate outcome, predicts health outcomes such as healing and need for subsequent surgery. In this study, there were no statistically significant differences between the active and sham groups on clinical outcomes such as movement at the fracture site, pain, and tenderness. Thus, Sharrard s health outcome data do not show that noninvasive electrical bone growth stimulation delivers an advantage over placebo. In 2011, Griffin et al. published a Cochrane review of electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults. (13) In addition to the 3 RCTs reviewed above, the systematic review included a 1984 study by Barker et al. that randomized 17 participants with tibial non-union to electromagnetic field stimulation or sham treatment. (14) Thus, 4 studies with a total of 125 participants were included for analysis. The primary outcome measure was the proportion of participants whose fractures had united at a fixed time point. For this outcome, the overall pooled effect size was small and not statistically significant (risk ratio [RR]: 1.96; 95% confidence interval [CI]: 0.86 to 4.48). Interpretation is limited due to the substantial clinical and statistical heterogeneity in the pooled analysis. In addition, there was no reduction in pain found in 2 trials, and none of the studies reported functional outcomes. The authors concluded that electromagnetic stimulation may offer some benefit in the treatment of delayed union and non-union, but the evidence is inconclusive and insufficient to inform current practice. Section Summary. Two randomized sham-controlled trials have been identified on the treatment of delayed union with PEMF. In the Sharrard study, radiographic healing was improved at 12 weeks, but there were no statistically significant differences between groups for clinical outcomes. In the study by Shi et al., only the rate of healing at an average of 4.8 months was statistically significant, and it is not clear if this is a pre-specified endpoint. The time to healing was not reduced by PEMF. Additional study is needed to permit greater certainty regarding the effect of this technology on delayed unions. Appendicular Skeletal Surgery A comprehensive search found 2 small randomized controlled trials on non-invasive electrical bone growth stimulation after orthopedic surgery. In 1988, Borsalino et al. reported a randomized double-blind sham-controlled trial of pulsed electromagnetic field stimulation (8 hours a day) in 32 patients who underwent femoral intertrochanteric osteotomy for osteoarthritis of the hip. (15) Radiographic measurements at 90 days revealed significant increases in the periosteal bone callus and in trabecular bone bridging at the lateral, but not the medial cortex. The study is limited by the small sample size and the lack of clinical outcomes.

7 Electrical Bone Growth Stimulation Page 7 of 42 A 2004 trial randomized 64 patients (144 joints with triple arthrodesis or subtalar arthrodesis) to pulsed electromagnetic field stimulation for 12 hours a day or to an untreated control condition. (16) Patients at high risk of non-fusion (rheumatoid arthritis, diabetes mellitus, or on oral corticosteroids) were excluded from the study. Blinded radiographic evaluation found a significant decrease in the time to union (12.2 weeks for talonavicular arthrodesis vs weeks in the control group; 13.1 weeks for calcaneocuboid fusion vs weeks for the control group). Clinical outcomes were not assessed. Fresh Fractures A multicenter, double-blind, randomized sham-controlled trial evaluated 12 weeks of pulsed electromagnetic field stimulation for acute tibial shaft fractures. (17) The endpoints examined were secondary surgical interventions, radiographic union, and patient-reported functional outcomes. Approximately 45% of patients were compliant with treatment (>6 hours daily use), and 218 patients (84% of 259) completed the 12-month follow-up. The primary outcome, the proportion of participants requiring a secondary surgical intervention because of delayed union or within 12 months after the injury, was similar for the 2 groups (15% active; 13% sham). Per protocol analysis comparing patients who actually received the prescribed dose of pulsed electromagnetic field stimulation versus sham treatment also showed no significant difference between groups. Secondary outcomes, which included surgical intervention for any reason (29% active; 27% sham), radiographic union at 6 months (66% active; 71% sham), and the SF-36 (Short Form) Physical Component Summary (44.9 active; 48.0 sham) and Lower Extremity Functional Scales at 12 months (48.9 active; 54.3 sham), also did not differ significantly between the groups. This sham-controlled RCT does not support a benefit for electromagnetic stimulation as an adjunctive treatment for acute tibial shaft fractures. Another smaller (n=53) multicenter double-blind, randomized sham-controlled trial found no advantage of PEMF for the conservative treatment of fresh (< 5 days from injury) scaphoid fractures. (18) Outcomes included the time to clinical and radiological union and functional outcome. Stress Fractures In 2008, Beck et al. reported a well-conducted randomized controlled trial (n=44) of capacitively coupled electric fields (OrthoPak) for healing acute tibial stress fractures. (19) Patients were instructed to use the device for 15 hours each day and usage was monitored electronically. Healing was confirmed when hopping 10 cm high for 30 seconds was accomplished without pain. Although an increase in the hours of use per day was associated with a reduction in the time to healing, there was no difference in the rate of healing between treatment and placebo. Power analysis indicated that this number of patients was sufficient to detect a difference in healing time of 3 weeks, which was considered to be a clinically significant effect. Other analyses, which suggested that electrical stimulation might be effective for the radiological healing of more severe stress fractures, were preliminary and a beneficial effect was not observed for clinical healing.

8 Electrical Bone Growth Stimulation Page 8 of 42 Invasive Bone Growth Stimulation A comprehensive search for implantable bone stimulators identified a small number of case series, all of which focused on foot and ankle arthrodesis in patients at high risk for (summarized in reference (20)). Risk factors for included smoking, diabetes mellitus, Charcot (diabetic) neuroarthropathy, steroid use, and previous. The largest case series described outcomes of foot or ankle arthrodesis in 38 high-risk patients. (21) Union was observed in 65% of cases by follow-up evaluation (n=18) or chart review (n=20). Complications were reported in 16 (40%) cases, including 6 cases of deep infection and 5 cases of painful or prominent bone stimulators necessitating stimulator removal. A multicenter retrospective review described outcomes from 28 high-risk patients with arthrodesis of the foot and ankle. (22) Union was reported for 24 (86%) cases at an average of 10 weeks; complications included breakage of the stimulator cables in 2 patients and hardware failure in 1 patient. Five patients required additional surgery. Prospective controlled trials are needed to evaluate this procedure. The 1992 TEC Assessment indicated that semi-invasive bone growth stimulators are no longer in wide use. (12) Clinical Input Received through Physician Specialty Societies and Academic Medical Centers While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted In response to requests, input was received from 5 academic medical centers while this policy was under review in The input supported use of noninvasive electrical bone growth stimulation for the treatment of fracture s or congenital pseudoarthroses of the appendicular skeleton. Input agreed that noninvasive electrical bone growth stimulation is investigational for immediate post-surgical treatment after appendicular skeletal surgery and treatment of fresh fractures. A majority of reviewers considered the use of noninvasive electrical bone growth stimulation to be investigational for the treatment of delayed union, for arthrodesis, or for the treatment of failed arthrodesis. Summary There is evidence from randomized controlled trials (RCTs) and systematic reviews of clinical trials that noninvasive electrical stimulators improve fracture healing for patients with fracture non-union. This evidence is not from high-quality RCTs; however, and systematic reviews provide qualified support for this conclusion. Based on the available evidence and the lack of other options for patients with non-union, electrical stimulation may be considered medically necessary for the U.S. Food and Drug Administration (FDA)-approved indications of fracture s or congenital pseudoarthroses in the appendicular skeleton when specific criteria are met. There is insufficient evidence to permit conclusions regarding the efficacy of noninvasive electrical bone growth stimulation for treatment of stress fractures or delayed union, or following surgery of the appendicular skeleton. In addition, a recent randomized trial found no benefit of electrical bone growth stimulation for fresh fractures. Use of noninvasive electrical bone growth stimulation for these conditions is considered investigational.

9 Electrical Bone Growth Stimulation Page 9 of 42 The literature for implantable bone stimulators of the appendicular skeleton consists of a small number of case series. In addition, no semi-invasive devices have FDA clearance or approval. The use of invasive or semi-invasive electrical bone growth stimulators is considered investigational. CODING The following codes for treatment and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or noncoverage of these services as it applies to an individual member. CPT/HCPCS Electrical stimulation to aid bone healing; noninvasive (non-operative) Electrical stimulation to aid bone healing; invasive (operative) E0747 Osteogenesis stimulator, electrical, noninvasive, other than spinal applications E0749 Osteogenesis stimulator, electrical, surgically implanted DIAGNOSES Malunion of fracture Nonunion of fracture (code includes pseudoarthrosis/pseudarthrosis) ICD-10 Diagnosis (Effective October 1, 2014) M96.0 Pseudarthrosis after fusion or arthrodesis Q74.0 Other congenital malformations of upper limb(s), including shoulder girdle S42.001K Fracture of unspecified part of right clavicle, subsequent encounter for fracture with S42.002K Fracture of unspecified part of left clavicle, subsequent encounter for fracture with S42.011K Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for S42.012K Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for S42.014K Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for S42.015K Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for S42.017K Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for S42.018K Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for S42.021K Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with S42.022K Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with S42.024K Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with

10 Electrical Bone Growth Stimulation Page 10 of 42 S42.025K S42.031K S42.032K S42.034K S42.035K S42.201K S42.202K S42.211K S42.212K S42.214K S42.215K S42.221K S42.222K S42.224K S42.225K S42.231K S42.241K S42.242K S42.251K S42.252K S42.254K S42.255K S42.261K S42.262K Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for Unspecified fracture of upper end of right humerus, subsequent encounter for Unspecified fracture of upper end of left humerus, subsequent encounter for fracture with Unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for Unspecified displaced fracture of surgical neck of left humerus, subsequent encounter for Unspecified nondisplaced fracture of surgical neck of right humerus, subsequent encounter for Unspecified nondisplaced fracture of surgical neck of left humerus, subsequent encounter for 2-part displaced fracture of surgical neck of right humerus, subsequent encounter for 2-part displaced fracture of surgical neck of left humerus, subsequent encounter for 2-part nondisplaced fracture of surgical neck of right humerus, subsequent encounter for 2-part nondisplaced fracture of surgical neck of left humerus, subsequent encounter for 3-part fracture of surgical neck of right humerus, subsequent encounter for fracture with 4-part fracture of surgical neck of right humerus, subsequent encounter for fracture with 4-part fracture of surgical neck of left humerus, subsequent encounter for fracture with Displaced fracture of greater tuberosity of right humerus, subsequent encounter for Displaced fracture of greater tuberosity of left humerus, subsequent encounter for Nondisplaced fracture of greater tuberosity of right humerus, subsequent encounter for Nondisplaced fracture of greater tuberosity of left humerus, subsequent encounter for Displaced fracture of lesser tuberosity of right humerus, subsequent encounter for Displaced fracture of lesser tuberosity of left humerus, subsequent encounter for

11 Electrical Bone Growth Stimulation Page 11 of 42 S42.264K S42.265K S42.271K S42.272K S42.291K S42.292K S42.294K S42.295K S42.301K S42.302K S42.311K S42.312K S42.321K S42.322K S42.324K S42.325K S42.331K S42.332K S42.334K S42.335K S42.341K S42.342K S42.344K S42.345K Nondisplaced fracture of lesser tuberosity of right humerus, subsequent encounter for Nondisplaced fracture of lesser tuberosity of left humerus, subsequent encounter for Torus fracture of upper end of right humerus, subsequent encounter for fracture with Torus fracture of upper end of left humerus, subsequent encounter for fracture with Other displaced fracture of upper end of right humerus, subsequent encounter for Other displaced fracture of upper end of left humerus, subsequent encounter for Other nondisplaced fracture of upper end of right humerus, subsequent encounter for Other nondisplaced fracture of upper end of left humerus, subsequent encounter for Unspecified fracture of shaft of humerus, right arm, subsequent encounter for Unspecified fracture of shaft of humerus, left arm, subsequent encounter for Greenstick fracture of shaft of humerus, right arm, subsequent encounter for Greenstick fracture of shaft of humerus, left arm, subsequent encounter for fracture with Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for Displaced transverse fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced transverse fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced transverse fracture of shaft of humerus, left arm, subsequent encounter for Displaced oblique fracture of shaft of humerus, right arm, subsequent encounter for Displaced oblique fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced oblique fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced oblique fracture of shaft of humerus, left arm, subsequent encounter for Displaced spiral fracture of shaft of humerus, right arm, subsequent encounter for Displaced spiral fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced spiral fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced spiral fracture of shaft of humerus, left arm, subsequent encounter for

12 Electrical Bone Growth Stimulation Page 12 of 42 S42.351K S42.352K S42.354K S42.355K S42.361K S42.362K S42.364K S42.365K S42.391K S42.392K S42.401K S42.402K S42.411K S42.412K S42.414K S42.415K S42.421K S42.422K S42.424K S42.425K S42.431K S42.432K S42.434K S42.435K Displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for Displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for Displaced segmental fracture of shaft of humerus, right arm, subsequent encounter for Displaced segmental fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced segmental fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced segmental fracture of shaft of humerus, left arm, subsequent encounter for Other fracture of shaft of right humerus, subsequent encounter for fracture with Other fracture of shaft of left humerus, subsequent encounter for fracture with Unspecified fracture of lower end of right humerus, subsequent encounter for Unspecified fracture of lower end of left humerus, subsequent encounter for fracture with Displaced simple supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Displaced simple supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Nondisplaced simple supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Nondisplaced simple supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Displaced comminuted supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Displaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Nondisplaced comminuted supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Nondisplaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Displaced fracture (avulsion) of lateral epicondyle of right humerus, subsequent encounter for Displaced fracture (avulsion) of lateral epicondyle of left humerus, subsequent encounter for Nondisplaced fracture (avulsion) of lateral epicondyle of right humerus, subsequent encounter for Nondisplaced fracture (avulsion) of lateral epicondyle of left humerus, subsequent encounter for

13 Electrical Bone Growth Stimulation Page 13 of 42 S42.441K S42.442K S42.444K S42.445K S42.447K S42.448K S42.451K S42.452K S42.454K S42.455K S42.461K S42.462K S42.464K S42.465K S42.471K S42.472K S42.474K S42.475K S42.481K S42.482K S42.491K S42.492K S42.494K S42.495K Displaced fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Displaced fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Nondisplaced fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Nondisplaced fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Incarcerated fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Incarcerated fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Displaced fracture of lateral condyle of right humerus, subsequent encounter for Displaced fracture of lateral condyle of left humerus, subsequent encounter for Nondisplaced fracture of lateral condyle of right humerus, subsequent encounter for Nondisplaced fracture of lateral condyle of left humerus, subsequent encounter for Displaced fracture of medial condyle of right humerus, subsequent encounter for Displaced fracture of medial condyle of left humerus, subsequent encounter for Nondisplaced fracture of medial condyle of right humerus, subsequent encounter for Nondisplaced fracture of medial condyle of left humerus, subsequent encounter for Displaced transcondylar fracture of right humerus, subsequent encounter for Displaced transcondylar fracture of left humerus, subsequent encounter for fracture with Nondisplaced transcondylar fracture of right humerus, subsequent encounter for Nondisplaced transcondylar fracture of left humerus, subsequent encounter for Torus fracture of lower end of right humerus, subsequent encounter for fracture with Torus fracture of lower end of left humerus, subsequent encounter for fracture with Other displaced fracture of lower end of right humerus, subsequent encounter for Other displaced fracture of lower end of left humerus, subsequent encounter for Other nondisplaced fracture of lower end of right humerus, subsequent encounter for Other nondisplaced fracture of lower end of left humerus, subsequent encounter for

14 Electrical Bone Growth Stimulation Page 14 of 42 S42.91xK S42.92xK S49.001K S49.002K S49.011K S49.012K S49.021K S49.022K S49.031K S49.032K S49.041K S49.042K S49.091K S49.092K S49.101K S49.102K S49.111K S49.112K S49.121K S49.122K S49.131K S49.132K S49.141K S49.142K Fracture of right shoulder girdle, part unspecified, subsequent encounter for fracture with Fracture of left shoulder girdle, part unspecified, subsequent encounter for fracture with Unspecified physeal fracture of upper end of humerus, right arm, subsequent encounter for Unspecified physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type I physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type I physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type II physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type II physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter Harris Type III physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter Harris Type III physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type IV physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type IV physeal fracture of upper end of humerus, left arm, subsequent encounter for Other physeal fracture of upper end of humerus, right arm, subsequent encounter for Other physeal fracture of upper end of humerus, left arm, subsequent encounter for Unspecified physeal fracture of lower end of humerus, right arm, subsequent encounter for Unspecified physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type I physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type I physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type II physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type II physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter Harris Type III physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter Harris Type III physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type IV physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type IV physeal fracture of lower end of humerus, left arm, subsequent encounter for

15 Electrical Bone Growth Stimulation Page 15 of 42 S49.191K Other physeal fracture of lower end of humerus, right arm, subsequent encounter for S49.192K Other physeal fracture of lower end of humerus, left arm, subsequent encounter for S52.001K Unspecified fracture of upper end of right ulna, subsequent encounter for closed S52.001N Unspecified fracture of upper end of right ulna, subsequent encounter for open S52.002K Unspecified fracture of upper end of left ulna, subsequent encounter for closed S52.002N Unspecified fracture of upper end of left ulna, subsequent encounter for open S52.011K Torus fracture of upper end of right ulna, subsequent encounter for fracture with S52.012K Torus fracture of upper end of left ulna, subsequent encounter for fracture with S52.021K Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed S52.021N Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open S52.022K Displaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for closed S52.022N Displaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open S52.024K Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed S52.024N Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open S52.025K Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for closed S52.025N Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open S52.031K Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for closed S52.031N Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open S52.032K Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed S52.032N Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open S52.034K Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for closed S52.034N Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open S52.035K Nondisplaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed S52.035N Nondisplaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open

16 Electrical Bone Growth Stimulation Page 16 of 42 S52.041K Displaced fracture of coronoid process of right ulna, subsequent encounter for closed S52.041N Displaced fracture of coronoid process of right ulna, subsequent encounter for open S52.042K Displaced fracture of coronoid process of left ulna, subsequent encounter for closed S52.042N Displaced fracture of coronoid process of left ulna, subsequent encounter for open S52.044K Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for closed S52.044N Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for open S52.045K Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for closed S52.045N Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for open S52.091K Other fracture of upper end of right ulna, subsequent encounter for closed fracture with S52.091N Other fracture of upper end of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.092K Other fracture of upper end of left ulna, subsequent encounter for closed fracture with S52.092N Other fracture of upper end of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.101K Unspecified fracture of upper end of right radius, subsequent encounter for closed S52.101N Unspecified fracture of upper end of right radius, subsequent encounter for open S52.102K Unspecified fracture of upper end of left radius, subsequent encounter for closed S52.102N Unspecified fracture of upper end of left radius, subsequent encounter for open S52.111K Torus fracture of upper end of right radius, subsequent encounter for fracture with S52.112K Torus fracture of upper end of left radius, subsequent encounter for fracture with S52.121K Displaced fracture of head of right radius, subsequent encounter for closed fracture with S52.121N Displaced fracture of head of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.122K Displaced fracture of head of left radius, subsequent encounter for closed fracture with S52.122N Displaced fracture of head of left radius, subsequent encounter for open fracture S52.124K type IIIA, IIIB, or IIIC with Nondisplaced fracture of head of right radius, subsequent encounter for closed S52.124N Nondisplaced fracture of head of right radius, subsequent encounter for open

17 Electrical Bone Growth Stimulation Page 17 of 42 S52.125K Nondisplaced fracture of head of left radius, subsequent encounter for closed S52.125N Nondisplaced fracture of head of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.131K Displaced fracture of neck of right radius, subsequent encounter for closed fracture with S52.131N Displaced fracture of neck of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.132K Displaced fracture of neck of left radius, subsequent encounter for closed fracture with S52.132N Displaced fracture of neck of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.134K Nondisplaced fracture of neck of right radius, subsequent encounter for closed S52.134N Nondisplaced fracture of neck of right radius, subsequent encounter for open S52.135K Nondisplaced fracture of neck of left radius, subsequent encounter for closed S52.135N Nondisplaced fracture of neck of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.181K Other fracture of upper end of right radius, subsequent encounter for closed fracture with S52.181N Other fracture of upper end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.182K Other fracture of upper end of left radius, subsequent encounter for closed fracture with S52.182N Other fracture of upper end of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.201K Unspecified fracture of shaft of right ulna, subsequent encounter for closed fracture with S52.201N Unspecified fracture of shaft of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.202K Unspecified fracture of shaft of left ulna, subsequent encounter for closed fracture with S52.202N Unspecified fracture of shaft of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.211K Greenstick fracture of shaft of right ulna, subsequent encounter for fracture with S52.212K Greenstick fracture of shaft of left ulna, subsequent encounter for fracture with S52.221K Displaced transverse fracture of shaft of right ulna, subsequent encounter for closed S52.221N Displaced transverse fracture of shaft of right ulna, subsequent encounter for open S52.222K Displaced transverse fracture of shaft of left ulna, subsequent encounter for closed S52.222N Displaced transverse fracture of shaft of left ulna, subsequent encounter for open

18 Electrical Bone Growth Stimulation Page 18 of 42 S52.224K Nondisplaced transverse fracture of shaft of right ulna, subsequent encounter for closed S52.224N Nondisplaced transverse fracture of shaft of right ulna, subsequent encounter for open S52.225K Nondisplaced transverse fracture of shaft of left ulna, subsequent encounter for closed S52.225N Nondisplaced transverse fracture of shaft of left ulna, subsequent encounter for open S52.231K Displaced oblique fracture of shaft of right ulna, subsequent encounter for closed S52.231N Displaced oblique fracture of shaft of right ulna, subsequent encounter for open S52.232K Displaced oblique fracture of shaft of left ulna, subsequent encounter for closed S52.232N Displaced oblique fracture of shaft of left ulna, subsequent encounter for open S52.234K Nondisplaced oblique fracture of shaft of right ulna, subsequent encounter for closed S52.234N Nondisplaced oblique fracture of shaft of right ulna, subsequent encounter for open S52.235K Nondisplaced oblique fracture of shaft of left ulna, subsequent encounter for closed S52.235N Nondisplaced oblique fracture of shaft of left ulna, subsequent encounter for open S52.241K Displaced spiral fracture of shaft of ulna, right arm, subsequent encounter for closed S52.241N Displaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open S52.242K Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed S52.242N Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open S52.244K Nondisplaced spiral fracture of shaft of ulna, right arm, subsequent encounter for closed S52.244N Nondisplaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open S52.245K Nondisplaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed S52.245N Nondisplaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open S52.251K Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for closed S52.251N Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for S52.252K open Displaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for closed S52.252N Displaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open

19 Electrical Bone Growth Stimulation Page 19 of 42 S52.254K Nondisplaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for closed S52.254N Nondisplaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open S52.255K Nondisplaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for closed S52.255N Nondisplaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open S52.261K Displaced segmental fracture of shaft of ulna, right arm, subsequent encounter for closed S52.261N Displaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open S52.262K Displaced segmental fracture of shaft of ulna, left arm, subsequent encounter for closed S52.262N Displaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open S52.264K Nondisplaced segmental fracture of shaft of ulna, right arm, subsequent encounter for closed S52.264N Nondisplaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open S52.265K Nondisplaced segmental fracture of shaft of ulna, left arm, subsequent encounter for closed S52.265N Nondisplaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open S52.271K Monteggia's fracture of right ulna, subsequent encounter for closed fracture with S52.271N Monteggia's fracture of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.272K Monteggia's fracture of left ulna, subsequent encounter for closed fracture with S52.272N Monteggia's fracture of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.281K Bent bone of right ulna, subsequent encounter for closed S52.281N Bent bone of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.282K Bent bone of left ulna, subsequent encounter for closed S52.282N Bent bone of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.291K Other fracture of shaft of right ulna, subsequent encounter for closed fracture with S52.291N Other fracture of shaft of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.292K Other fracture of shaft of left ulna, subsequent encounter for closed fracture with S52.292N Other fracture of shaft of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with S52.301K Unspecified fracture of shaft of right radius, subsequent encounter for closed